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Structural heart interventions training in Europe
International Journal of Cardiology 202 (2016) 532–534
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Structural heart interventions training in Europe Konstantinos Marmagkiolis a,e,⁎, Dabit Arzamendi b, Omer Goktekin c, Mehmet Cilingiroglu d,f a
Citizens Memorial Hospital, Heart and Vascular Institute, Bolivar, MO, USA Servicio de Cardiología, Hospital de Sant Pau i de la Santa Creu, Universidad de Barcelona, Barcelona, Spain c Bezmialem Faculty of Medicine, Department of Cardiology, Istanbul, Turkey d Koc University, School of Medicine, Istanbul, Turkey e University of Missouri, Columbia, MO, USA f Arkansas Heart Hospital, Little Rock, AR, USA b
a r t i c l e
i n f o
Article history: Received 25 March 2015 Accepted 18 September 2015 Available online 21 September 2015 Keyword: Structural heart disease interventions training
a b s t r a c t Background: Structural heart interventions have made major strides over the last years with the introduction of TAVR, percutaneous mitral valve repair and adult congenital heart disease procedures. Methods: As part of the SCAI SHD Early Career Task Force committee, we complied a survey of 17 questions using a Survey Monkey website. We sent invitations twice by email to 183 European program directors of interventional cardiology fellowship programs in Europe. Results: The most commonly performed procedures performed by the fellows were transseptal punctures, TAVR, BAV, PFO and BMV. For the rest of the structural procedures, each fellow performed b10 procedures during their training. Conclusion: Structural heart interventions training will keep expanding over the next years with the introduction of newer devices and techniques and accumulation of experience. Given the small number of the more rare structural procedures, it becomes apparent that we need to design national or international training networks to provide adequate training experience to all trainees. © 2015 Elsevier Ireland Ltd. All rights reserved.
1. Objective Structural heart interventions have made major strides over the last years with the introduction of transcatheter aortic valve replacement (TAVR), percutaneous mitral valve and adult congenital heart disease procedures. Most interventional cardiology training programs worldwide have included structural training in their curriculum to keep up with the increased need for well-trained interventionalists able to perform those complex procedures. As part of the Society for Cardiovascular Angiography and Interventions (SCAI) Structural Heart Disease (SHD) Early Career Task Force, we have previously published surveys on the status of structural training in the US and Canada [1,2]. Although in the US the formal interventional cardiology training is overseen by the Accreditation Council for Graduate Medical Education (ACGME) and in Canada by the Canadian Association of Interventional Cardiology (CAIC), in Europe there is not currently an official organization to regulate the interventional cardiology fellowship training programs. The European Association of Percutaneous Cardiovascular Interventions (EAPCI) has proposed a
⁎ Corresponding author at: Citizens Memorial Hospital, Heart and Vascular Institute, 1500 N Oakland Rd, Bolivar, MO 65613, USA. E-mail address: [email protected] (K. Marmagkiolis).
http://dx.doi.org/10.1016/j.ijcard.2015.09.017 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
standard of interventional training but it cannot mandate changes to the existing cardiology fellowship programs that are regulated by the academic institutions in the individual European countries. The purpose of our survey was to collect information about SHD training in European fellowship programs and to evaluate the opinion of interventional cardiology program directors (PDs) who lead and orchestrate structural heart interventions training. Following previous surveys performed in the US and Canada, this study aims to describe differences in structural training between large academic centers worldwide and identify weaknesses and limitations with the ambition to design an international training network on structural cardiac interventions. 2. Methods As part of the SCAI SHD Early Career Task Force committee, we complied a survey of 17 questions which were approved by the authors (Table 1). We created a Survey Monkey website to gather and analyze the survey results. We sent invitations twice by email to 183 European program directors of interventional cardiology fellowship programs and requested the completion of our online survey with a one month difference. The purpose of the survey was to describe the current state of structural heart interventions training in Europe, to evaluate the role of didactics, ancillary imaging training and collaboration with pediatric interventionalists and to roughly estimate the actual number of structural procedures performed by each interventional fellow-in-training. Furthermore, we sought advice by program directors who are actively involved in SHD training regarding adequacy of the current training, improvement options, funding and collaboration.
K. Marmagkiolis et al. / International Journal of Cardiology 202 (2016) 532–534
533
Table 1 Survey questions. 1) Is your institution involved in the percutaneous treatment of structural heart diseases? 2) How is the interventional training program structured? (Training only on coronary interventions, Training on coronary and structural interventions, Training on coronary, structural and endovascular interventions, Formal one year structural training) 3) Do you offer a short-term intensive track option for focused training in specific structural interventions? 4) Is there dedicated time in the training program to address structural interventions? 5) In your opinion as Program Director, is this enough time? 6) In your opinion does a dedicated structural fellowship program detract from the overall interventional program fellowship training? 7) Would you consider having a dedicated year for structural interventional training? 8) Do you follow a didactic program (lectures) for structural training? 9) Are your fellows trained in interpreting the following? (Cardiac CT scans, Cardiac MRIs, TTE, TEE, ICE) 10) Does your institution collaborate with a pediatric interventionalist for structural interventional work? 11) Of the following procedures, please estimate how many your fellows-in-training perform in 1 year? (ICE, Transseptal punctures, ASD, PFO, BAV, BMV, BPV, ASA, LAA Closure, TAVR, TPVR, MitraClip Placement or other Mitral device, Perivalvular leak repair, VSD, Coronary fistula occlusions, PDA occlusions, Aortic coarctation treatment) 12) Of the following procedures, how many do you think should be performed by fellows-in-training in order to become proficient? (ICE, Transseptal punctures, ASD, PFO, BAV, BMV, BPV, ASA, LAA Closure, TAVR, TPVR, MitraClip Placement or other Mitral device, Perivalvular leak repair, VSD, Coronary fistula occlusions, PDA occlusions, Aortic coarctation treatment) 13) How do you think a position in structural interventional training should be funded? (Government, Industry funds, Hospital funds, Other) 14) How is your structural training program funded? (Government, Industry funds, Hospital funds, Other) 15) How do fellows submit their applications for the structural training program? (Via email to the program director or the program co-ordinator, Though the program website) 16) Is your application process internal or is it open to external applicants? (Internal, Open to external applicants) 17) Who is the person to contact for information on training in structural interventional cardiology? (Program Name, Program Director Name, Contact Info)
3. Results Of the 183 program directors who received the survey, 10.9% (n: 20) completed it. From the responding training centers, 90% (n: 18) are involved in structural heart interventions. 56.25% (n: 9) offer training on coronary and structural interventions, 31.25% (n: 5) on coronary, structural and endovascular interventions and 12.5% (n: 2) only on coronary interventions. Interestingly, there were no programs offering a dedicated year for structural interventional training but 64.71% (n: 11) of them would consider it. 41.18% (n: 7) offer a short-term intensive track option for focused training in specific structural interventions. 64.71% (n: 11) of the responding programs have designated dedicated time to address structural interventions and 52.94% (n: 7) of the PDs believe that this time is enough for the fellows to achieve the required knowledge and skills. 64.71% (n: 11) of the PDs do not believe that a dedicated structural fellowship program detracts trainees from the overall fellowship training program. 64.71% (n: 11) of the responding institutions have a didactic program for structural training and 52.94% (n: 9)
collaborate with pediatric interventionalists. Most of the fellows trained in interpreting Trans-thoracic (TTE) and Trans-Esophageal Echocardiograms (TEE) and Cardiac CT. Only 23.53% (n: 3) of the responders offer adequate training in Cardiac MRI and 6.25% (n: 1) in Intra-Cardiac Echocardiograms (ICE) 46.15%. The most commonly performed procedures performed by the fellows were transseptal punctures, Transcatheter Aortic Valve Replacements (TAVR), Balloon Aortic Valvuloplasty (BAV), Patent Foramen Ovale (PFO) closure and Balloon Mitral Valvuloplasty (BMV). For the rest of the structural procedures, each fellow performed b 10 procedures during their training (Fig. 1). The PDs indicated that N 10 procedures should be performed by the fellows-in-training in order to become proficient (Fig. 1). Furthermore, only for two types of procedures (transseptal punctures and TAVR), the number of actually performed procedures is higher that the number needed to attain proficiency. Program funding was almost equally distributed to government (46.15%), hospital funds (38.46%) and industry funds (38.46%). The PDs believe that their programs should be sponsored by Government
Fig. 1. Average number of procedures performed per fellow-in-training and estimated number needed to attain proficiency.
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K. Marmagkiolis et al. / International Journal of Cardiology 202 (2016) 532–534
and hospital funds (64.71%) rather than industry funds (29.41%). Most of the programs (93.33%) accept applications via email to the program director or the program coordinator and 68.75% (n: 11) are open to external applicants. 4. Conclusion Our survey clearly shows that in Europe structural heart interventions training is attached to the formal coronary interventional training or offered with “mini-fellowships” focused on specific structural interventions. This differs from North American institutions where dedicated structural one-year fellowship programs have been increasing over the last years. Program directors have formed a special curriculum for training on SHD, collaborate with pediatric interventionalists and offer dedicated time for the fellows-in-training to achieve better knowledge and skills on structural procedures. Regarding training on ancillary imaging modalities, Cardiac MRI interpretation and ICE interpretation appear to be less favored over TTE, TEE and Cardiac CT training. This probably occurs due to the designated interpretation of Cardiac MRI to radiologists rather than cardiologists and because of the increased cost of ICE. In accordance to our previous surveys in the US and Canada, fellows perform a satisfactory number of the most common procedures (transseptal punctures, TAVR, BAV, PFO) with an increased experience in BMV probably due to the increased number of patients with mitral stenosis in Europe compared to North America. However, the PDs believe that fellows-in-training should perform more procedures than they actually do in 15 out of the total 17 types of procedure. 5. Limitations Our survey is limited by the small number of participating institutions (only 10.9%). This is probably due to the language barriers as our survey was provided only in English language. Furthermore, an official database with an accurate list and contact information of all the training programs in Europe is currently unavailable. The survey assessed the subjective opinions of the PDs and rough estimates of the procedures
performed by their fellows in training rather than accurate numbers. Whether fellows were involved as first or assistant operators is not defined. The survey was initially designed in the US and was planned to be international; thus some procedures which were not approved in the United States (like left atrial appendage closure or various mitral valve repair devices) were not included. 6. Practice implications Structural heart interventions training will keep expanding over the next years with the introduction of newer devices and techniques and accumulation of experience. With a more efficient regulatory framework, our European colleagues have always achieved quicker access to more advanced transcatheter devices and have accumulated more significant experience on cutting edge technology compared to North American interventionalists. Our survey demonstrates the status of SHD training in Europe and the perspective from the program directors' standpoint. Given the small number of the more rare structural procedures, it becomes apparent that we need to design national or international training networks to provide adequate training experience to all trainees. Conflict of interest statement The authors report no relationships that could be construed as a conflict of interest. References [1] K. Marmagkiolis, A. Hakeem, M. Cilingiroglu, S. Bailey, C. Ruiz, Z. Hijazi, H. Herrmann, A. Zajarias, S. Goldberg, T. Feldman, 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. 80 (4) (2012) 706–711. [2] K. Marmagkiolis, F. Alqoofi, A. Asgar, R.H. Boone, M. Cilingiroglu, Structural heart diseases interventional training programs in Canada, Can. J. Cardiol. 29 (11) (2013) 1524–1526.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Structural heart interventions training in Europe Konstantinos Marmagkiolis a,e,⁎, Dabit Arzamendi b, Omer Goktekin c, Mehmet Cilingiroglu d,f a
Citizens Memorial Hospital, Heart and Vascular Institute, Bolivar, MO, USA Servicio de Cardiología, Hospital de Sant Pau i de la Santa Creu, Universidad de Barcelona, Barcelona, Spain c Bezmialem Faculty of Medicine, Department of Cardiology, Istanbul, Turkey d Koc University, School of Medicine, Istanbul, Turkey e University of Missouri, Columbia, MO, USA f Arkansas Heart Hospital, Little Rock, AR, USA b
a r t i c l e
i n f o
Article history: Received 25 March 2015 Accepted 18 September 2015 Available online 21 September 2015 Keyword: Structural heart disease interventions training
a b s t r a c t Background: Structural heart interventions have made major strides over the last years with the introduction of TAVR, percutaneous mitral valve repair and adult congenital heart disease procedures. Methods: As part of the SCAI SHD Early Career Task Force committee, we complied a survey of 17 questions using a Survey Monkey website. We sent invitations twice by email to 183 European program directors of interventional cardiology fellowship programs in Europe. Results: The most commonly performed procedures performed by the fellows were transseptal punctures, TAVR, BAV, PFO and BMV. For the rest of the structural procedures, each fellow performed b10 procedures during their training. Conclusion: Structural heart interventions training will keep expanding over the next years with the introduction of newer devices and techniques and accumulation of experience. Given the small number of the more rare structural procedures, it becomes apparent that we need to design national or international training networks to provide adequate training experience to all trainees. © 2015 Elsevier Ireland Ltd. All rights reserved.
1. Objective Structural heart interventions have made major strides over the last years with the introduction of transcatheter aortic valve replacement (TAVR), percutaneous mitral valve and adult congenital heart disease procedures. Most interventional cardiology training programs worldwide have included structural training in their curriculum to keep up with the increased need for well-trained interventionalists able to perform those complex procedures. As part of the Society for Cardiovascular Angiography and Interventions (SCAI) Structural Heart Disease (SHD) Early Career Task Force, we have previously published surveys on the status of structural training in the US and Canada [1,2]. Although in the US the formal interventional cardiology training is overseen by the Accreditation Council for Graduate Medical Education (ACGME) and in Canada by the Canadian Association of Interventional Cardiology (CAIC), in Europe there is not currently an official organization to regulate the interventional cardiology fellowship training programs. The European Association of Percutaneous Cardiovascular Interventions (EAPCI) has proposed a
⁎ Corresponding author at: Citizens Memorial Hospital, Heart and Vascular Institute, 1500 N Oakland Rd, Bolivar, MO 65613, USA. E-mail address: [email protected] (K. Marmagkiolis).
http://dx.doi.org/10.1016/j.ijcard.2015.09.017 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
standard of interventional training but it cannot mandate changes to the existing cardiology fellowship programs that are regulated by the academic institutions in the individual European countries. The purpose of our survey was to collect information about SHD training in European fellowship programs and to evaluate the opinion of interventional cardiology program directors (PDs) who lead and orchestrate structural heart interventions training. Following previous surveys performed in the US and Canada, this study aims to describe differences in structural training between large academic centers worldwide and identify weaknesses and limitations with the ambition to design an international training network on structural cardiac interventions. 2. Methods As part of the SCAI SHD Early Career Task Force committee, we complied a survey of 17 questions which were approved by the authors (Table 1). We created a Survey Monkey website to gather and analyze the survey results. We sent invitations twice by email to 183 European program directors of interventional cardiology fellowship programs and requested the completion of our online survey with a one month difference. The purpose of the survey was to describe the current state of structural heart interventions training in Europe, to evaluate the role of didactics, ancillary imaging training and collaboration with pediatric interventionalists and to roughly estimate the actual number of structural procedures performed by each interventional fellow-in-training. Furthermore, we sought advice by program directors who are actively involved in SHD training regarding adequacy of the current training, improvement options, funding and collaboration.
K. Marmagkiolis et al. / International Journal of Cardiology 202 (2016) 532–534
533
Table 1 Survey questions. 1) Is your institution involved in the percutaneous treatment of structural heart diseases? 2) How is the interventional training program structured? (Training only on coronary interventions, Training on coronary and structural interventions, Training on coronary, structural and endovascular interventions, Formal one year structural training) 3) Do you offer a short-term intensive track option for focused training in specific structural interventions? 4) Is there dedicated time in the training program to address structural interventions? 5) In your opinion as Program Director, is this enough time? 6) In your opinion does a dedicated structural fellowship program detract from the overall interventional program fellowship training? 7) Would you consider having a dedicated year for structural interventional training? 8) Do you follow a didactic program (lectures) for structural training? 9) Are your fellows trained in interpreting the following? (Cardiac CT scans, Cardiac MRIs, TTE, TEE, ICE) 10) Does your institution collaborate with a pediatric interventionalist for structural interventional work? 11) Of the following procedures, please estimate how many your fellows-in-training perform in 1 year? (ICE, Transseptal punctures, ASD, PFO, BAV, BMV, BPV, ASA, LAA Closure, TAVR, TPVR, MitraClip Placement or other Mitral device, Perivalvular leak repair, VSD, Coronary fistula occlusions, PDA occlusions, Aortic coarctation treatment) 12) Of the following procedures, how many do you think should be performed by fellows-in-training in order to become proficient? (ICE, Transseptal punctures, ASD, PFO, BAV, BMV, BPV, ASA, LAA Closure, TAVR, TPVR, MitraClip Placement or other Mitral device, Perivalvular leak repair, VSD, Coronary fistula occlusions, PDA occlusions, Aortic coarctation treatment) 13) How do you think a position in structural interventional training should be funded? (Government, Industry funds, Hospital funds, Other) 14) How is your structural training program funded? (Government, Industry funds, Hospital funds, Other) 15) How do fellows submit their applications for the structural training program? (Via email to the program director or the program co-ordinator, Though the program website) 16) Is your application process internal or is it open to external applicants? (Internal, Open to external applicants) 17) Who is the person to contact for information on training in structural interventional cardiology? (Program Name, Program Director Name, Contact Info)
3. Results Of the 183 program directors who received the survey, 10.9% (n: 20) completed it. From the responding training centers, 90% (n: 18) are involved in structural heart interventions. 56.25% (n: 9) offer training on coronary and structural interventions, 31.25% (n: 5) on coronary, structural and endovascular interventions and 12.5% (n: 2) only on coronary interventions. Interestingly, there were no programs offering a dedicated year for structural interventional training but 64.71% (n: 11) of them would consider it. 41.18% (n: 7) offer a short-term intensive track option for focused training in specific structural interventions. 64.71% (n: 11) of the responding programs have designated dedicated time to address structural interventions and 52.94% (n: 7) of the PDs believe that this time is enough for the fellows to achieve the required knowledge and skills. 64.71% (n: 11) of the PDs do not believe that a dedicated structural fellowship program detracts trainees from the overall fellowship training program. 64.71% (n: 11) of the responding institutions have a didactic program for structural training and 52.94% (n: 9)
collaborate with pediatric interventionalists. Most of the fellows trained in interpreting Trans-thoracic (TTE) and Trans-Esophageal Echocardiograms (TEE) and Cardiac CT. Only 23.53% (n: 3) of the responders offer adequate training in Cardiac MRI and 6.25% (n: 1) in Intra-Cardiac Echocardiograms (ICE) 46.15%. The most commonly performed procedures performed by the fellows were transseptal punctures, Transcatheter Aortic Valve Replacements (TAVR), Balloon Aortic Valvuloplasty (BAV), Patent Foramen Ovale (PFO) closure and Balloon Mitral Valvuloplasty (BMV). For the rest of the structural procedures, each fellow performed b 10 procedures during their training (Fig. 1). The PDs indicated that N 10 procedures should be performed by the fellows-in-training in order to become proficient (Fig. 1). Furthermore, only for two types of procedures (transseptal punctures and TAVR), the number of actually performed procedures is higher that the number needed to attain proficiency. Program funding was almost equally distributed to government (46.15%), hospital funds (38.46%) and industry funds (38.46%). The PDs believe that their programs should be sponsored by Government
Fig. 1. Average number of procedures performed per fellow-in-training and estimated number needed to attain proficiency.
534
K. Marmagkiolis et al. / International Journal of Cardiology 202 (2016) 532–534
and hospital funds (64.71%) rather than industry funds (29.41%). Most of the programs (93.33%) accept applications via email to the program director or the program coordinator and 68.75% (n: 11) are open to external applicants. 4. Conclusion Our survey clearly shows that in Europe structural heart interventions training is attached to the formal coronary interventional training or offered with “mini-fellowships” focused on specific structural interventions. This differs from North American institutions where dedicated structural one-year fellowship programs have been increasing over the last years. Program directors have formed a special curriculum for training on SHD, collaborate with pediatric interventionalists and offer dedicated time for the fellows-in-training to achieve better knowledge and skills on structural procedures. Regarding training on ancillary imaging modalities, Cardiac MRI interpretation and ICE interpretation appear to be less favored over TTE, TEE and Cardiac CT training. This probably occurs due to the designated interpretation of Cardiac MRI to radiologists rather than cardiologists and because of the increased cost of ICE. In accordance to our previous surveys in the US and Canada, fellows perform a satisfactory number of the most common procedures (transseptal punctures, TAVR, BAV, PFO) with an increased experience in BMV probably due to the increased number of patients with mitral stenosis in Europe compared to North America. However, the PDs believe that fellows-in-training should perform more procedures than they actually do in 15 out of the total 17 types of procedure. 5. Limitations Our survey is limited by the small number of participating institutions (only 10.9%). This is probably due to the language barriers as our survey was provided only in English language. Furthermore, an official database with an accurate list and contact information of all the training programs in Europe is currently unavailable. The survey assessed the subjective opinions of the PDs and rough estimates of the procedures
performed by their fellows in training rather than accurate numbers. Whether fellows were involved as first or assistant operators is not defined. The survey was initially designed in the US and was planned to be international; thus some procedures which were not approved in the United States (like left atrial appendage closure or various mitral valve repair devices) were not included. 6. Practice implications Structural heart interventions training will keep expanding over the next years with the introduction of newer devices and techniques and accumulation of experience. With a more efficient regulatory framework, our European colleagues have always achieved quicker access to more advanced transcatheter devices and have accumulated more significant experience on cutting edge technology compared to North American interventionalists. Our survey demonstrates the status of SHD training in Europe and the perspective from the program directors' standpoint. Given the small number of the more rare structural procedures, it becomes apparent that we need to design national or international training networks to provide adequate training experience to all trainees. Conflict of interest statement The authors report no relationships that could be construed as a conflict of interest. References [1] K. Marmagkiolis, A. Hakeem, M. Cilingiroglu, S. Bailey, C. Ruiz, Z. Hijazi, H. Herrmann, A. Zajarias, S. Goldberg, T. Feldman, 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. 80 (4) (2012) 706–711. [2] K. Marmagkiolis, F. Alqoofi, A. Asgar, R.H. Boone, M. Cilingiroglu, Structural heart diseases interventional training programs in Canada, Can. J. Cardiol. 29 (11) (2013) 1524–1526.