Ten Essential Adjunctive Skillsets for the Budding Structural Interventionist

Structural heart disease intervention is unique in its need for different collaborative and supportive specialties to work together when providing optimal patient care. Commonly referred to as the “Heart Team,” these people can include the cardiac surgeon, anesthesiologist, radiologist, intensivist, echocardiographer, and interventional cardiologist, among others. To enhance the relationship between different disciplines, the interventional cardiologist needs to acquire superb leadership skills to carefully orchestrate the whole team. 

During my training and through observing my mentors, I’ve come to appreciate the importance of acquiring these leadership qualities. But equally important is the development of other essential adjunctive skills that complement your training in structural heart disease intervention. Mostly these revolve around learning appropriate patient selection, having a complete understanding of procedures and devices, and maintaining procedural safety and efficiency.

Here are 10 essential adjunctive skillsets you need to acquire to evolve into a competent structural heart interventionist:

1. Know your cardiac anatomy: Cardiac anatomy is the foundation for structural heart interventions and the prerequisite for correlating multiple cardiac imaging modalities including fluoroscopy, transesophageal echocardiography (TEE), intracardiac echocardiography (ICE), and cardiac CT. Gaining a deep understanding of detailed cardiac anatomy is essential to integrate the anatomical concepts with imaging modalities and interventional techniques. Familiarity in correlating anatomy to different imaging modalities will make you a safer and more efficient interventionalist, especially when faced with difficult and variable anatomy.

2. Read TEEs like an echocardiographer: When performing echo-based interventional procedures like a MitraClip (Abbot Vascular) implant, knowing how to read the TEE in front of you will enable you to communicate effectively with the echocardiographer. This way, you can both speak a “common language” in describing these and your fluoroscopy images, and you will be able to more effectively perform technical maneuvers.

3. Co-analyze cardiac CTs: You might have stellar CT interpretation knowledge, but having the forethought to analyze each of your patient’s scans with your radiologist or cardiologist CT expert will lead to better outcomes when correlating to fluoroscopic landmarks. CT skills will become even more essential when transcatheter mitral valve replacement—which is technically more complex than TAVR and requires a detailed understanding of CT analysis—proves efficient and becomes routinely used.

4. Learn ICE: Familiarity with ICE is essential, especially when you want to avoid general anesthesia and TEE for your patient. The beauty of ICE is that it is user-friendly, affords independence, and provides adequate imaging of cardiac chambers and color Doppler without anesthesia.

5. Master advanced cardiovascular hemodynamics: As a structural interventionalist, your job is not limited to treating heart disease but also includes solving unclear and difficult diagnostic dilemmas. This demands developing a detailed systematic approach and knowing what questions to ask based on the problem faced. Your process should be executed with meticulous and constant evaluation of the collected data, and you should be ready to perform additional diagnostic interventions and provocative maneuvers, if necessary, to tailor your clinical decision-making.

6. Know your congenital cardiology: Increased survival of patients with complex congenital heart disease means that interventionalists are more likely to undertake interventions in patients with complex anatomy and unusual pathology. Having a solid knowledge in congenital cardiology will allow you to be more adaptable to variations in complex anatomy and adjust your preprocedural planning accordingly based on the interpretations of different acquired cardiac imaging modalities. You will also need to become more creative in developing technical solutions.

7. Be ready with bailout interventional procedures: When time-sensitive and life-threatening emergencies occur, you need to be able to perform smoothly and calmly. Becoming well-versed in bailout procedures—like emergency pericardiocentesis, techniques to retrieve embolized materials, insertion of percutaneous left ventricular assist devices such as Impella (Abiomed), extracorporeal membrane oxygenation, and vessel embolization—will help you do just that. Sign up for workshops and cath simulations to keep your skills on par, and always prepare crash kits for such procedures in your lab.

8. Comprehend cardiac surgical techniques: Interventionalists have often been criticized of being technology-driven as opposed to our surgical counterparts who are said to be more technique-driven. Many interventionalists can fall into the notorious trap of not learning what surgeons do technically, and this will not serve them well. The importance of your surgical knowledge will come into play when performing percutaneous interventions after congenital surgeries and treating post-surgical complications such as paravalvular leaks.

9. Train in iliofemoral and aortic peripheral interventions: These skills are imperative if you are going to successfully handle the common endovascular complications during large-bore arterial vascular access procedures such as dissection, perforation, AV fistula, and femoral pseudoaneurysm. If not trained in peripheral intervention, make a point to join an interventional radiologist or vascular surgeon to learn the technical basics and also to acknowledge your technical limitations. Never be shy to ask for help.

10. Keep up-to-date with device technology: Get down to the nitty-gritty when it comes to the engineering principles behind cardiac device technology, and make sure you truly understand how that cool novel contraption works before ever using it. This will enhance your knowledge of these devices’ limitations in specific anatomical substrates and help you troubleshoot in case of device malfunction.