Conversations in Cardiology: For Fellows, How Much Structural Heart Disease Training Is Enough?

Morton KernMorton Kern, MD, of VA Long Beach Healthcare System and University of California, Irvine, often engages his colleagues via email in brief, informal dialogue on clinically relevant topics in interventional cardiology. With permission from the participants, TCTMD presents their conversations for the benefit of the interventional cardiology community. Your feedback is welcome—feel free to comment at the bottom of the page.


Kirk Garratt, MD (Christiana Care Health System, Newark, DE), asks:

I have a question for the group: I’m currently have a job opening for an interventionalist. Many of the applicants are fellows graduating this summer who claim to bring structural skills, but many will have had just 1 year of interventional cardiology training. I maintain that competency in structural heart procedures requires a dedicated year, in addition to a year of coronary/peripheral training, and so have not been interviewing these folks. However, the volume of applicants with this background makes me wonder if community standards are changing. Am I being too stern on this? Have others had good experiences with trainees who come out of a 1 year training experience with adequate skills in both structural and “routine” interventional procedures?

Jeffrey W. Moses, MD (Columbia University Medical Center, New York, NY), replies:

There is no way to achieve competency in aortic valves, mitral clip/balloon, paravalvular leak, and LAA closure woven into learning basic cath/PCI. A dedicated year is mandatory.

Christopher J. White (Ochsner Medical Center, New Orleans, LA), replies:

The minimum requirement for a fourth-year interventional fellow is 250 PCIs, and I think we all agree, the more the better. There just isn’t enough time to gain an additional set of skills for neuro, peripheral, or structural in a 1-year program. We have had a dedicated second-year training program for 25 years. I would never hire a 1-year fellow for anything but a coronary job, unless I was willing to provide on-the-job training for additional skills.

I can tell you that my fifth-year fellows with dedicated structural training are not finding good jobs. They are being offered positions in low-volume community hospitals.

Charanjit S. Rihal, MD (Mayo Clinic, Rochester, MN), replies:

I completely agree. I am hearing from fellows who have completed interventional cardiology plus an additional "structural" year. I agree that it takes additional experience, and that positions that allow for investing in career development are best for newly minted interventional cardiologists.

Bonnie H. Weiner, MD (Worcester Medical Center, MA), replies:

Kirk, I am with you. Unless you plan to spend that first year on faculty training them, I don’t think what any of them get in 1 year of training is sufficient.

Pinak Bipin Shah, MD (Brigham and Women’s Hospital, Boston, MA), replies:

I would agree with Kirk. I believe it is imperative to have a full second year devoted to structural intervention to be considered for a structural faculty position.

It is hard enough to become proficient in coronaries in just 1 year. I do not feel it is possible to get a reasonable enough experience in vascular or structural in order to practice independently if that experience is obtained in that same year.

Neal Kleiman, MD (Houston Methodist DeBakey Heart and Vascular Institute, TX), replies:

Looks like we are all on the same page. A single year isn’t nearly enough to establish competence in these different areas in addition to establishing the level of skill we expect of PCI operators. This will probably become even more true as the variety of structural (and coronary) procedures increases. As an institution, we tend not to look favorably at applicants who profess to have learned to do all these things in a short period of time.

David J. Cohen, MD (Saint Luke’s Mid America Heart Institute, Kansas City, MO), replies:

I agree with everything that has been said so far—a dedicated year of additional training should be required for structural work given the incredible breadth of diseases and treatments that it encompasses. And beyond learning the technical aspects of the various procedures (which are substantial), one needs to master the imaging requirements as well as understanding the clinical aspects (ie, indications, complication management, etc).

Thinking that one can accomplish all of this for both coronary intervention and structural intervention in less than 2 years is incredibly naive.

Kleiman replies:

If it helps, we actually summarized some of these arguments in a paper in CCI last November.

Mladen I. Vidovich, MD (Jesse Brown VA Medical Center, Chicago, IL), replies:

Two years and the second should structural. (That raises the eternal point: should general cardiology last 3 or could it be abbreviated to 2, so that long training does not make our (sub)specialty noncompetitive?)

Mitchell W. Krucoff, MD (Duke University Medical Center, Durham, NC), replies:

This reads like what I tell patients about getting a second opinions in complex options scenarios: If you get many opinions from many doctors, you can be sure there is no right answer. If you get one opinion from many doctors, you can have no doubt about what to do

On this one, Kirk, you can have no doubt about the right answer!

Steven R. Bailey, MD (University of Texas Health Sciences Center at San Antonio, TX), replies:

Agree with the arguments of all. Training in structural heart disease needs to focus on this area including patient assessment, review and integration of studies, as well as performing the procedure. This should be built on top of a sound interventional education.

Mauricio G. Cohen, MD (University of Miami Hospital, FL), replies:

It is impossible to accomplish the necessary experience to perform structural heart interventions right out of fellowship. There are a number of cognitive and procedural skills that need to be acquired, including access management, interpretation of hemodynamics, imaging, physiology, and deep understanding of devices and techniques that are completely different across structural interventions. Moreover, just a few programs are able to offer all type of interventions with an adequate volume for training.

We have started a nonaccredited extra year that includes international experience in Rotterdam and Colombia. Our fellows are very appreciative of their international experience.

I agree with the rest of the group. An extra year of training is needed.

Susheel Kodali, MD (NewYork-Presbyterian Hospital/Columbia University Medical Center), replies:

I think it is clear that additional training is required. However, another question is: should we as a group get together to try and standardize the training or at least provide some guidelines? Should there be minimum skills required to say you are a trained structural interventionalist? Is there a minimum number of structural procedures? Does it need to include all structural procedures (PFO, ASD, LAAO, TAVR, PVL closure, MitraClip, etc.)? This would make it challenging as volume at different programs varies. Personally I think it should dedicated imaging training in CT and echo. Not so much that they are independent in doing TEEs but enough that they can understand what they are looking at and understand the 3D anatomy. Now that there are more programs offering structural training, this may be the time to start standardizing or at least setting guidelines. I personally would be interested.

Duane S. Pinto, MD (Beth Israel Deaconess Medical Center, Boston, MA), replies:

I wholeheartedly agree with codifying expectations and requirements. I also agree with some idea of volume requirements but recognize that this will exacerbate current obsessions with “getting numbers.” I also think that we should expect more in terms of the work of being a doctor outside of the laboratory. Many have adopted the “minimalist approach to TAVR” which includes apparently for some trainees a minimalist approach to understanding hemodynamics, outpatient clinic, inpatient follow-up after the procedure, etc. There should be some requirement for outpatient structural clinic and inpatient consultation in addition to specific numbers of devices deployed and holes closed.

Larry S. Dean, MD (UW Medicine, Seattle, WA), replies:

We require a structural year.

Paul Sorajja, MD (Minneapolis Heart Institute, MN), replies:

Completely agree with everyone's comments and sentiment. One year dedicated to structural heart disease is needed. It is also recognized that the year is just the foundation and that years of further experience are needed for independence. Many of us who are older are doing these cases without the formal year of training, and that practice requires a considerable amount of dedication that shouldn't be overestimated.

Pinto replies:

Conversations in CardiologyThere is definitely a generation gap in this and a doctor versus proceduralist split. Older docs (some who did 2-year cardiology fellowships when Braunwald's text was 1 inch thick) say, "Why not? Add another year.”

Conversely, I hear many trainees reconsidering electrophysiology because of a fifth year skipping chief residencies, etc. (I know, I know, what's 1 year in a 40-year career if you love it. If you love it, it won't be work, and all the other platitudes.)

Nonetheless, a $250K opportunity cost is on their mind as well a training fatigue at almost 30, never having had a real job that pays more than a physician assistant or nurse practitioner that they supervise who works 40 hours a week.

Don't get me wrong, I believe 1 year is just enough to make you the least-experienced person doing PCI in your group and the last person to invest in to lead a valuable new program to run/compete (PAD, TAVR, CTO) when there is usually someone already more experienced there already, sometimes with a specific intention to engender failure.

To do this right, we should be smarter and simultaneously try to remove the senior "moonlighting" PGY3 and PGY6 years in internal medicine and general cardiology to make room for 2-year interventional as some surgical specialties have done.


Ajay J. Kirtane, MD (NewYork-Presbyterian Hospital/Columbia University Medical Center), replies:

These are great points and I concur entirely (especially regarding PGY6).

Lloyd Klein, MD (Rush Medical College, Chicago, IL), replies:


Your points are excellent from the standpoint of what would be best for our profession. Not so likely to happen, though, because that isn’t how decisions are made.

Mort Kern, MD (VA Long Beach Healthcare System and University California, Irvine), replies:

Bottom line seems to be that fellows should have an additional year for structural training because of the increasingly specialized equipment and skill sets. None should forsake the coronary training for intervention, but a shorter general cardiology training period should be considered. 



Rahul Sharma

7 years ago
A dedicated year of structural heart training is necessary to acquire the cognitive, procedural and imaging skills to be a proclaimed "structuralist." Great points have been mentioned about the financial hit one takes in doing multiple years of training. Something needs to be done; can we cut down on required years of residency/fellowship training? Not going to be easy. Many of my colleagues in other professions (law, business) often spend 5-10 years establishing themselves after graduate school, so I don't necessarily begrudge the fact that I'm now in my 9th consecutive year of post-graduate training. I look at it as a right of passage to get to where I want to be; hopefully will get there :) The real elephant in the room is the unchecked and exorbitant cost of undergrad and medical school in the United States...this expense often leads to educational debt that can prevent capable trainees from pursuing advanced fellowships because of the pressure to get a job and pay off student loans. As I near the end of my great structural heart fellowship year, I can say without a doubt that being at a high volume structural center where you are trained in a direct hands-on operator fashion in the full spectrum of structural heart, while also taking autonomous coronary/STEMI call, is essential. There is also great learning to be had in the nuances of program building and growth; something that many fellowship programs don't formally teach. How much structural training is enough? Probably when you can autonomously perform TAVR with both commercially available valve platforms, MitraClip while understanding the manipulation of TEE imaging views, ASD/PFO closure with TEE and ICE, LAAO closure, some experience with the other rarer structural interventions, and percutaneous LVAD assisted complex high risk PCI, then you've had enough training. I don't look at a dedicated structural heart year as being an extra....its actually the bare minimum. The learning and growth should then continue in your earlier career. With all this great training, what comes concurrently? A tough job search in which you are both more marketable and less marketable in equal measure. I am blessed to have landed my "dream job," but the 'invisible hand' of the job market leads many structurally trained FITs to take a position that doesn't necessarily provide the promise of what they have been trained to do. Maybe not a big deal to some, but it is a big deal for many. This dyssynchrony leads to a supply-demand mismatch and under-employment. If we were to tell an economist that there's a profession where 8-9 years of training still doesn't land you a job that's a match for your skillset, then that would be a huge red flag. Perhaps the focus of this conversation should shift from "how much structural training is enough" to "do we need more structurally trained fellows right now?"

Pradeep Yadav

7 years ago
As everyone eluded, there is no doubt that a full year of dedicated training is needed to be an independent structural operator. But even the programs offering year long SHD fellowships need "quality check". Most of such fellowships don't offer the full spectrum of SHD, have low volume (except TAVR), some just started doing LAAC, Clip (tough to imagine expert training if the teacher is starting to learn the tool himself). Real SHD training programs are very very few. Urgent need of SHD COCATS!
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