Certification for Structural Heart Disease: Where Do We Stand?

Every specialty in medicine has gone through a maturation process before it is established as a unique discipline. There is no reason to believe that this will not continue into the future. The process begins shortly after new methods or procedures receive approval and are introduced into clinical practice. Typically the new methods are initially taken up by enthusiastic early adopters, usually led by the investigators involved in validating trials. As it becomes clear that the data in well controlled clinical trials can be duplicated in clinical practice, more and more physicians seek to obtain training and offer the new methodology. The novel knowledge/procedures are also gradually introduced into residency/fellowship programs, resulting in a combination of physicians who have received training as house officers and those who have gained experience “on the job” or in short-term educational programs. This variability is duplicated by differences in the types, duration, and intensity of training of the residency programs themselves. At some point in time the knowledge/experience base becomes sufficiently large that it seems clear that only individuals who have focused their interest in the field are fully qualified to practice the new methods. This usually occurs concomitant with the availability of physicians who have been fully educated in the new techniques as house officers. At that point consideration turns to the establishment of a new credential or specialty, and to what specific training requirements and case experience should be requisite. Thought is given as to whether the new field merits a certificate of added qualifications or represents a new specialty, and how to assess or test for competence. It would seem that involvement in the management of structural heart disease is beginning to approach such a juncture. Although clinics dedicated to heart valve disease or adult congenital heart disease have existed for many years, the explosion of the field of structural disease was fueled by the development of TAVR. The field has largely resided within the subspecialty of interventional cardiology and its interaction with cardiac surgery since that time. But it was not long before transcatheter mitral valve clipping and left atrial appendage occlusion procedures were introduced into clinical practice, and a number of percutaneous procedures directed to congenital disease were consolidated into the interventional armamentarium. Catheter closure of perivalvular leaks of prosthetic valves was an additional skill. It is not surprising, therefore, that the first training programs focused on structural heart disease emerged within interventional cardiology. While experience was initially incorporated into the standard interventional fellowship, an additional year of training devoted to structural heart procedures has increasingly emerged. Usually such programs require prior completion of a standard interventional cardiology fellowship, and often entail a separate application process. However, at present, training in structural interventions remains variable within interventional fellowship programs. Percutaneous treatment of structural heart disease requires the participation of other specialists who, in aggregate, form the heart team. Of particular importance, guidance of the procedures required orientation in three dimensional space, information generally supplied by echocardiography, and accurate measurements of cardiac and great vessel size by CT or CMR. Of course, participation of anesthesiologists and cardiac surgeons was of fundamental importance. Nevertheless, the emergence of specialized training in these non-interventional specialties has been much slower. However, there is an increasing recognition that special expertise and exposure to structural procedures is as important for these other disciplines as for the interventional cardiologists. A number of prior publications have discussed the needs for and status of standardized training for certification and perhaps ultimately specialization in structural heart disease interventions and/or imaging.1.Marmagkiolis K Hakeem A Cilingiroglu M et al.The Society for Cardiovascular Angiography and Interventions structural heart disease early career task force survey results—endorsed by the Society for Cardiovascular Angiography and Interventions.Catheter Cardiovasc Interv. 2012; 80: 706-711Google Scholar, 2.Ruiz CE Feldman TE Hijazi ZM et al.Interventional fellowship in structural and congenital heart disease for adults.JACC Cardiovasc Inter. 2010; 3: e1-e15Google Scholar, 3.Herrmann HC Baxter S Ruiz CE et al.Results of the Society of Cardiac Angiography and Interventions survey of physicians and training directors on procedures for structural and valvular heart disease.Catheter Cardiovasc Interv. 2010; 76 (doi: 10.1002/ccd.22703): E106-E110Google Scholar, 4.Rajagopalan B Buber J Yadav PK Cullen MW State of structural and congenital heart disease interventional training in United States and Canada: an assessment by the American College of Cardiology fellows-in-training section leadership council.J Am Coll Cardiol Intventions. 2016; 9 (doi: 10.1016/j.jcin.2016.06.033): 1854-1856Google Scholar, 5.American College of Cardiology Structural Heart Disease Fellowship Programs Database. http://www.acc.org/membership/sections-andcouncils/fellows-in-training-section/training-resources/structural-heart-disease-and-congenital-interventional-fellowship-programs. Accessed October 4, 2016Google Scholar, 6.Kalra A Bhatt DL Pinto DS et al.Accreditation and funding for a 24 month advanced interventional cardiology fellowship program: a call-to-action for optimal training of the next generation of interventionalists.Catheter Cardiovasc Interv. 2016; 88 (doi: 10.1002/ccd.26661): 1010-1015Google Scholar, 7.Kalra A Fellowships in advanced interventional and structural cardiology need structure, planning and collaboration—stat!. July 5, 2016. https://www.tctmd.com/news/fellowships-advanced-interventionaland-structural-cardiology-need-structure-planning-and. Accessed October 4, 2016Google Scholar As of 2016, a survey of adult interventional training programs found that 36 had specific training devoted to structural heart disease, while nine pediatric programs had such training.4.Rajagopalan B Buber J Yadav PK Cullen MW State of structural and congenital heart disease interventional training in United States and Canada: an assessment by the American College of Cardiology fellows-in-training section leadership council.J Am Coll Cardiol Intventions. 2016; 9 (doi: 10.1016/j.jcin.2016.06.033): 1854-1856Google Scholar It appears that the number of programs are growing. However, these programs are limited by a lack of a standardized curriculum, uncertainty regarding the requisite number of cases for competency, in some cases a relatively low volume, no clear mechanism for funding, and variability in the necessary prior training and application process. In addition, in prior experience I found that credentialing agencies require a defined, unique, and codified base of knowledge underpinning the field. Certainly this latter is necessary to construct some valid means of testing. Thus, it seems apparent that the field of structural heart is not yet fully mature enough to warrant specialization. It is of interest that, of all the members of the heart team, the greatest interest in and movement toward specialization seems to come from the imagers. This issue of Structural Heart contains an opinion piece from experts in both intervention and imaging as to the knowledge, skill set, and attitude necessary to be an interventional imager for structural heart disease.8.Wang DD, Geske J, Choi AD, et al. Interventional imaging for structural heart disease: challenges and new frontiers of an emerging multi-disciplinary field. Struct Heart. 2019;this issue. doi: 10.1080/24748706.2019.1595238.Google Scholar It would seem that the information and skills necessary for effective structural disease imaging is felt to be more unique and less prevalent in the imaging community than that for interventional procedures is in the interventional community. In fact, these authors even propose specific knowledge, skills, and volumes that might be considered in establishing expertise in interventional imaging in structural disease. It is to be anticipated that other disciplines will follow shortly. So where do we stand in regard to structural heart disease as a specialty and credentialing of expertise? It is clear that the number and type of interventional procedures of all kinds for structural heart disease are increasing. Given the recent demonstration of benefit of percutaneous treatment of low-risk patients with aortic stenosis9.Mack MJ, Leon MB, Thourani VH, et al.; for the PARTNER 3 Investigators. Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients. Massachusetts Med Soc. March 17, 2019, at NEJM.org. [Epub ahead of print] Copyright 2019. DOI: 10.1056/NEJMoa1814052.Google Scholar and heart failure patients with functional mitral regurgitation,10.Stone GW Lindenfeld JA Abraham WT et al.for the COAPT Investigators. Transcatheter Mitral-Valve Repair in Patients with Heart Failure.N Engl J Med. 2018; 379 (doi: 10.1056/NEJMoa1806640): 2307-2318Google Scholar I believe we are entering another period of explosive growth of structural heart procedures. Recent positive early results for percutaneous procedures to achieve renal artery denervation and balloon pulmonary artery dilation for systemic and pulmonary hypertension respectively promise to further expand therapies for structural disorders. So it is anticipated that, as the percentage of effort that the heart team spends treating structural disease and the special skills necessary for effective therapy both increase, the requisite conditions for establishing a specialty and credentials may well be met. In fact, Structural Heart Journal itself is a testimony to the emergence of the discipline. While the requisite conditions are not met at present, it is appropriate to begin to think about and even to propose potential criteria for training and demonstrating expertise in the field. One can speculate that someday there may be a cadre of specialists who identify as structural heart disease interventionalists, imagers, anesthesiologists, and perhaps others. The author has no conflicts of interest to disclose.

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