Introduction:
Structural heart disease intervention is dynamic and continually advancing. Challenges in establishing dedicated training programs stem from the personalized nature of the procedures and their lower volumes compared to coronary interventions. This lack of consensus on the optimal training approach led to the proposal of a novel paradigm, emphasizing the acquisition of core technical skills and periprocedural care. This approach facilitates adaptation to innovative procedures, promoting lifelong learning by mastering foundational skills.
What Is Structural Heart Disease Intervention?
Structural heart disease interventions constitute a novel realm of percutaneous treatments encompassing diverse congenital and acquired conditions formerly addressed through surgery or left untreated. The term spans non-coronary heart diseases, from septal defects to acquired valvular issues. This burgeoning field is characterized by its multidisciplinary nature, involving specialists such as cardiac imaging experts, clinical cardiologists, interventional cardiologists, interventional pediatricians, and cardiac surgeons. Selecting suitable patients for percutaneous intervention requires comprehensive studies, ongoing training, and familiarity with diverse materials and devices.
Additionally, catheterization laboratories must adapt to hybrid procedures. Grouped conditions include septal defects, valvular heart disease, vascular obstructions, fistulas, and others. Broadly, interventions fall into two categories: removing obstructions via dilation procedures with balloons, stents, or valved stents and occluding abnormal communications between cardiac chambers or vascular channels using closure devices or coils.
Viewing each SHD intervention as a combination of distinct building blocks allows for the teaching and assessing procedural competency based on these components rather than specific procedures, which evolve. Identifying ten key SHD building blocks, cognitive skills, and device-specific training enables effective planning and implementation of structural procedures. These building blocks also serve as a basis for addressing new clinical challenges through innovative use of skills and devices.
Assessing competency in each block individually during training allows for developing a competency-based framework, ensuring ongoing proficiency. For experienced practitioners, combining established building blocks with device-specific training facilitates competency in evolving procedures, exemplified by transcatheter mitral valve replacement.
What Are the Interventions in Structural Heart Disease?
Interventions for structural heart disease, such as transcatheter aortic valve replacement (TAVR), are rapidly evolving. In low-risk aortic stenosis (AS) patients, TAVR with the SAPIEN 3 valve demonstrated a lower primary endpoint at two years compared to surgery (SAVR). However, valve thrombosis rates were higher than TAVR. The Evolut Low-Risk Trial showed comparable outcomes for TAVR and SAVR at two years, but TAVR had a higher rate of permanent pacemaker implantation.
Various trials addressed additional aspects, including the ACTIVATION trial assessing PCI before TAVR, analyses of arrhythmias, cerebral protection in TAVR (REFLECT I trial), the SOLVE-TAVI trial comparing anesthesia types, and antithrombotic therapy studies like POPTAVI and ENVISAGE-TAVI AF.
Vascular access studies explored alternative approaches, and outcomes in kidney disease, coronary obstruction, and complications such as subclinical leaflet thrombosis were examined. The BASILICA technique showed promise in preventing coronary obstruction during TAVR.
What Are the Procedures Involved in Structural Heart Interventions?
Successful structural interventions hinge on a practitioner's adeptness with wires, catheters, venous and arterial access, and catheter placement in various cardiac chambers. Many structural trainees have prior coronary interventional training, where they acquire skills in basic catheterization laboratory procedures. Techniques in structural intervention often parallel those in coronary interventions, encompassing aspects like guide catheter management, covered stent deployment, and left ventricular support device insertion. The percutaneous coronary intervention is a tool in aortic valve structural interventions when coronary obstruction is a concern.
Large bore sheath management, commonly approached via the femoral route, involves assessing vessel characteristics through vascular imaging and implementing closure devices to minimize bleeding. Unconventional access methods, such as transthoracic, transhepatic, and transcranial routes, may be explored collaboratively with other specialties. Proficiency in managing vascular complications, including iliofemoral perforation during transcatheter aortic valve replacement (TAVR) is crucial.
Transseptal puncture (TSP) for structural heart disease (SHD) interventions are intricate due to challenging atrial septa, requiring specialized training, tools like SafeSept wire or electrocautery, and collaboration with electrophysiology colleagues. Detailed anatomical knowledge is crucial in reducing complications. Navigating within the left atrium post-TSP involves a 3D understanding of anatomy, intraprocedural imaging with transesophageal echocardiography (TEE), and precise communication with imaging partners.
Intraprocedural imaging integration involves combining preprocedural imaging with fluoroscopic guidance. Techniques like the telescoping catheter and various occlusion methods are essential for diverse structural procedures. Creating arteriovenous or transapical rails for support, utilizing snaring for wire rail creation and retrieval, and performing valvuloplasty procedures, particularly for aortic stenosis and, rarely, mitral valvuloplasty, are crucial components of structural interventions.
Mastery of advanced TSP techniques, cognitive skills for 3D relational anatomy, and integration of various imaging modalities are imperative for successful SHD interventions. Structural interventionalists must be well-versed in the vast array of available delivery systems and occlusive devices. The cross-fertilization of techniques and ideas remains essential in this evolving field.
What Are the Factors to Consider for Structural Heart Interventions?
Intricate hemodynamic monitoring is vital in structural heart disease (SHD) procedures, aiding preprocedural lesion assessment, early detection of hemodynamic instability, and response evaluation to interventions. Although invasive hemodynamic assessment has diminished with advanced imaging, it remains a core skill for structural interventionalists. Left ventricular apex entry, an advanced technique for specific cases, necessitates careful preprocedural imaging and exit planning due to potential complications like hemothorax.
Preprocedural planning for structural interventions is extensive, involving determining access routes, choosing devices, and establishing emergency plans. Comprehensive knowledge of prosthetic valve structures, device compatibilities, and specific procedural techniques is crucial. Operators must navigate the challenge of using equipment designed initially for coronary interventions in structural procedures. The expanding array of devices requires specific training, understanding the Food and Drug Administration–approved indications, and being aware of device limitations.
While no consensus exists on minimal procedural numbers for SHD training, a building blocks approach emphasizes component competencies. Training in each building block is ideally concentrated, and specialized SHD Fellowship programs have emerged. Competence maintenance involves regular procedures covering each building block, acknowledging that procedures like left ventricular access may be limited to specialized centers. Simulation or industry-based proctoring courses can be beneficial in cases of low procedural numbers, and ongoing education is essential to keep up with evolving devices and procedures.
Conclusion:
Structural heart interventions demand a multifaceted skill set encompassing hemodynamic expertise, intricate procedural techniques, and comprehensive device knowledge. The field’s evolution has led to specialized training programs, emphasizing a building blocks approach for competency. The interplay of preprocedural planning, adaptability to device variation, and ongoing education reflect the dynamic nature of structural interventions. As the landscape advances, maintaining procedural competence and staying abreast of innovations remain pivotal for structural interventionalists.
