Structural Heart | 2019
Certification for Structural Heart Disease: Where Do We Stand?
Abstract
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. 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. 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 andmovement toward specialization seems to