Survey Reflects US Structural Intervention Training in Its ‘Infancy’

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Not a single fellowship program in the United States offers sufficient interventional training in each of 15 advanced structural procedures to achieve minimum skill proficiency. This is only one of the findings of a survey published online July 20, 2012, ahead of print in Catheterization and Cardiovascular Interventions that reflects the disjointed and evolving state of current US training programs in the area of structural heart disease.

Konstantinos Marmagkiolis, MD, of William Beaumont Hospital (Royal Oak, MI), and colleagues sent a survey on behalf of the Society for Cardiovascular Angiography and Interventions (SCAI) to all 137 of the interventional fellowship program directors at institutions accredited by the Accreditation Council for Graduate Medical Education (ACGME). The survey sought information on the quality and quantity of structural heart disease training. Fifty (36.5%) of the institutions responded, of which most (86%) are involved in the percutaneous treatment of structural heart disease.

Programs, Opinions Show Wide Variation

Nine (29%) offer a 1-year training program in structural intervention after completion of interventional cardiology training, while 16 (51.6%) integrate structural intervention with coronary and peripheral training into the formal fellowship. Reflecting the diversity of opinion regarding such training, more than half of program directors (58.6%) believe incorporating structural training in the first year of an interventional cardiology fellowship program is insufficient, while roughly one-third of program directors believe that a dedicated structural program would detract from the overall program.

More than a third of structural training (39.3%) is achieved through assigning cases throughout the year to fellows, while one-quarter (25%) is through specialized conferences and courses. The survey also asked program directors about their views regarding the minimum number of annual procedures for 15 key structural interventions needed to develop proficiency, comparing it with the actual number of procedures performed (table 1).

Table 1. Interventional Procedures Performed at Structural Training Programs^a

^a All numbers are approximate.

The average number of procedures performed was higher than what program directors felt was necessary for only 4 procedures (ICE, BAV, PFO, and ASD closure), while only 5 of the responding institutions perform a sufficient volume for 10 of the 15 procedures. Overall, not a single center offers a sufficient volume in all of the 15 types of advanced structural procedures per year.

Funding was also assessed, reflecting an inconsistent framework and diverse opinions. Currently, half of the structural programs (n = 17) are funded within the existing ACGME interventional program as an integrated part of the overall fellowship program, and half are funded by grants (private, institutional, SCAI, or industry). More than half (60%) of program directors believe that government should fund structural fellowship programs, while 43% believe industry should contribute. Other proposed funding sources include Veterans Administration Hospital or private hospital contributions, medical societies, and philanthropy.

“From this survey, it is apparent that training in structural interventions is in its infancy except in a few centers in the [United States],” the authors conclude. “Most interventional cardiology training programs are involved in ‘some’ sort of structural interventions but only few of them offer a dedicated [structural heart disease] fellowship program.”

Many Devices Await FDA Approval

In a telephone interview with TCTMD, study coauthor Mehmet Cilingiroglu, MD, of the University of Pittsburgh Medical Center Heart and Vascular Institute (Pittsburgh, PA), noted that the survey results are not particularly surprising. “Some of these technologies are still in FDA trials in the United States and have yet to gain approval, such as the MitraClip,” he said. “There are 100 clips being deployed in Europe per month, and we barely make that number in the United States because we’re in the trial phase.”

He added that US centers vary widely in skill level. “Do you call a center that just does PFO or ASD closure but doesn’t have any experience in TAVR a ‘structural heart interventional center’?” Dr. Cilingiroglu asked. “That’s an open-ended discussion.”

Robert J. Sommer, MD, of Columbia University Medical Center (New York, NY), agreed that the field is still in its early stages. In an e-mail communication with TCTMD, he noted that “most institutions are learning the procedures from colleagues and at meetings. There are few training programs, many of which train in only some of the procedures. There are no standards for training in most procedures other than those determined by the device companies.”

According to Dr. Cilingiroglu, appropriate standards for structural interventional training are currently under discussion. “Do you truly need a year of dedicated training after x number of years already committed to becoming an interventional cardiologist?” he asked. “Some argue that is what you absolutely need, that just having a couple of TAVR procedures and being proctored is not good enough to do a clip procedure, which is completely separate. Others argue that we can give these skills to someone during their interventional cardiology fellowship.”

The European Option

“It is difficult to create a dedicated structural year as these procedures (other than PFO and ASD) are uncommon and unpredictable,” Dr. Sommer said. “It would be hard to create criteria for training as it would be difficult to ensure that a minimum number of each type of case would show up during the year. Thus, exposing as many people as possible to the small number of procedures seems a better training strategy.”

Spending time in Europe may also be a possibility. “Many people desire training in Europe,” Dr. Cilingiroglu said. “You do so much more volume because the devices are already CE approved. If you go to Europe, you will be able to get done in 3 to 6 months what I will do in 1 year in the United States.” He added that SCAI plans on expanding the survey to Europe and Canada to identify those centers that might be willing to accept US fellows for training in structural procedures.

Dr. Sommer expressed some doubt as to whether this tactic would be viable as an overall approach. “Training in Europe would be fine for some procedures (eg, LAA), but the unpredictability of the others limits this strategy,” he said. “Until [devices are] approved, most will continue to need on-the-job training as occurs now.”

Funding, though, remains “the huge outstanding issue,” Dr. Cilingiroglu pointed out. “Right now in the United States, the interventional programs are funded partly by the government, partly by SCAI, and partly by unrestricted educational grants,” he said. “For formal dedicated [structural] fellowships, who’s going to fund that? This is the biggest challenge we have right now.”

 

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Source:
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:Epub ahead of print.

 

 

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