ABC | Volume 111, Nº5, November 2018

Editorial Structural Heart Interventional Imagers – The New Face of Cardiac Imaging João L. Cavalcante 1,2 and Dee Dee Wang 3 Minneapolis Heart Institute, Abbott Northwestern Hospital, 1 Minneapolis - Minnesota Valve Science Center, Minneapolis Heart Institute Foundation, 2 Minneapolis, Minnesota Center for Structural Heart Disease, Henry Ford Health System, 3 Detroit - Michigan Mailing Address: João L. Cavalcante • Minneapolis Heart Institute - 800 East 28th Street, Suite 300, Minneapolis, Minnesota, 55407 Email: joao.cavalcante@allina.com Keywords Cardiology/education; Cardiology/trends; Diffusion of Innovation; Education, Medical, Graduate/trends; Multimodal Imaging/trends; Transcatheter AorticValveReplacement/economic. DOI: 10.5935/abc.20180232 With the aging of the world’s population, there has been a parallel growth of valvular heart disease. The development and establishment of less-invasive transcatheter aortic valve replacement (TAVR) has provided a different framework to approach these patients through a multi-disciplinary heart team for planning and treatment. This multi-disciplinary heart team allows the sharing of different expertise and knowledge in order to improve patient care. Although TAVR is one example, many other transcatheter structural heart interventions for the mitral valve, left atrial appendage, paravalvular leak closure, and tricuspid valve, will continue to expand the armamentarium of less-invasive therapies for these typically high-risk patients. Within this context of continued expansion of devices and procedures, there has been increased demand for physicians with specific procedural-based skills and advanced cardiac imaging training in both echocardiography and cardiac computed tomography (CCT). However, the relative novelty of this subspecialty, brings many challenges. In the presence of poorly defined training requisites and skill-sets and lack of appropriate procedural reimbursement and recognition of the advanced level of peri-procedural imaging and medical care provided, there are many barriers to sustainability and expansion of this unique subspecialty. Training in structural heart disease imaging Although training in multi-modality imaging has been well outlined, 1 there are no specific training guidelines and/or requirements for SHD imagers as demonstrated by the results of a recent European survey. 2 Some of the challenges currently faced by cardiology fellows who look for SHD imaging training include finding training centers with enough high-risk clinical volume and exposure to a variety of high-risk procedures so they can train beyond traditional TAVR procedures. This brings an inevitable question of whether adequate SHD imaging training should therefore be reserved to a small number of centers with sufficient knowledge and experience in these procedures. What should constitute the minimal portfolio of procedures, their degree of complexity, the number of cases performed for procedural planning and for intraprocedural guidance to achieve adequate proficiency are some of the questions whose answers remain unclear. The majority of high-volume programs can provide comprehensive exposure for adequate training, particularly in TAVR, Atrial Septal Defect (ASD) and Left Atrial Appendage (LAA) closure procedures. Transcatheter mitral valve repair with MitraClip system (Abbott Vascular, Menlo Park, CA) is also becoming increasingly more commonly performed and should become a standard part of the SHD imager training. On the other hand, transcatheter procedures such as paravalvular leak closure, transcatheter mitral valve replacement and percutaneous tricuspid interventions are more complex and less frequently performed, and therefore should involve different expectations for what is considered the minimal requirement to achieve proficiency. Important job attributes We have recently provided a brief outline including some of the main characteristics and attributes necessary for the success of Structural Heart Disease (SHD) imagers. 3 One of the key components is to have exquisite understanding of and training in these imaging modalities so the imager can integrate and succinctly present information to the heart team, as well as provide value for further recommendations in diagnostic testing and interpretation of data, particularly when there are conflicting reports. In pre-procedural planning, review and synthesis of serial imaging studies is required to evaluate for progressive changes in cardiac function, chamber size, and severity of valvular pathology. This is particularly important when multi-valvular disease is present, which can pose a challenge in both diagnostic and therapeutic decisions. More often than not, using multi-modality imaging and hemodynamic evaluation can be necessary to clarify the clinical question(s). During intraprocedural guidance, SHD imagers learn to be agile, focused, mindful and able to protect themselves from radiation exposure. The ability to apply multi-modality critical thinking to integrate and combine clinical information and imaging findings (fluoroscopy and TEE) implies a physician trained skill-set that imagers can develop overtime. Interventional imaging physician driving critical-thinking imaging becomes invaluable to procedural success, much more than any form of imaging overlay or fusion. In‑depth knowledge of particular devices and procedural steps, as well as clear, succinct and timely communication with the interventional cardiologist and other team members are critical attributes of a successful SHD Imager, thus implying solid knowledge of the timing and importance of his/her role. Post-procedurally, SHD imagers must be able to correlate imaging findings with intraprocedural results and potential 645