ABC | Volume 111, Nº5, November 2018

Editorial Cavalcante & Wang Structural heart imagers – the new face of cardiac imaging Arq Bras Cardiol. 2018; 111(5):645-647 device complications. Exposure to a variety of SHD interventions is required in order to generate sufficient imaging experience, to allow the mitigation of complications and to promote safety during high-risk transcatheter procedures. A SHD imager who has developed these unique skill sets will be an indispensable asset to a SHD heart team and a key component to achieve excellent procedure safety and outcomes. Given the dynamic nature of this field, continued changes are expected on the standard training curriculum, reflecting important updates in the medical literature, device iterations and procedural changes. This can be done by attending annual meetings and industry-sponsored seminars, participating in online CME opportunities and structural imaging workshops, all of which can help refresh and enhance imaging skills. Radiation exposure is a potential job hazard for the shd imager Although the issue of radiation exposure was not adequately studied until relatively recently, 4,5 it certainly represents one of the most important job hazards for the SHD imager. Both publications 4,5 confirm that the SHD imager can be subject to very high levels of radiation exposure in structural cases. Therefore, given the increased complexity of these procedures, which demand more fluoroscopic and imaging guidance, one can only hope that it remains an important area for future research and technological development. At present time, a number of simple measures, such as the use of protective lead apron, portable ceiling-suspended lead shield and distancing from the X-ray source, can provide important strategies to minimize exposure and the potential risk associated with it. 5,6 Work environments and hospital management teams need to be supportive of and accomodating to providing the necessary resources that can minimize the potential consequences of excessive radiation exposure outlined by the authors. Reimbursement and sustainability of work enviroment At the majority of programs in the United States, the SHD Interventional Imager is considered part of the non-invasive general cardiologist group. This occurs at private-practice groups, hospital-employed group-practices or at major academic centers. This creates a significant mismatch between the amount of time that is required to plan and guide complex SHD procedures, and the reimbursement currently allocated to the SHD imager. In the current model, the amount of work relative value units (wRVU) dictates the metrics for purposes of reimbursement and final wages. Simply put, the more procedures a physician does, the more studies he/she reads, the more he/she can charge. The current model does not reflect the time spent on procedural planning, the required skill-set to successfully guide complex SHD interventions, nor does it account for the potential adverse health-effects on the SHD imager, such as radiation exposure. Let’s take, for example, an uncomplicated MitraClip procedure. This Mitraclip procedure is dependent on intraprocedural transesophageal (TEE) guidance, and requires 90+mins of uninterrupted real-time TEE 3D imaging procedural guidance. This is billed as one umbrella SHD intraprocedural TEE code (93355), with an associated wRVU measure of 4.66, therefore amounting to a $230 charge. Within the same time frame, another “non‑invasive” cardiologist could have read 10‑15 transthoracic echocardiograms (valued at 1.3 wRVU per study) or 3-4 TEEs (valued at 2.3 wRVU per study), which demonstrates, by traditional productivity metrics, more value to an institution than the Interventional Imaging physician functioning as a second operator in the Mitraclip procedure who is additionally getting radiation exposure. [source: http:// asecho.org/2018-medicare-physician-fee-schedule-final-rule ]. SHD imagers must continue to advocate recognition for the unique requirements to thrive in this emerging subspecialty. Sustainability within a SHD imaging career track is directly dependent upon fair productivity metrics. Many graduating fellows show a clear interest in pursuing further SHD Interventional Imaging training. However, current reimbursement practice models will deter potential trainees from embracing this new subspecialty field of medicine. A salary-based model is more likely to facilitate a successful SHD imaging career, as opposed to the traditional wRVU productivity model. Until societal guidelines are established for this emerging field, differential procedural codes will continue to fall short on allocating and compensating SHD imaging time properly. Future directions The presence of a skilled SHD imager is critical to the growth and success of any high-volume SHD program. The recent, strongly positive results of the COAPT trial 7 emphasize the opportunity for amulti-societal level discussion. In order to allow sustainable growth and continue to provide the imaging support necessary for patient safety and the success of these high-risk transcatheter procedures, it is necessary to revise the current structural and payment model which provides insignificant acknowledgement to the SHD imager; a Co-operator who is absolutely necessary to successfully execute this procedure. Together, these findings emphasize the critical need for and the opportunity to recognize SHD interventional imaging as a subspecialty within Cardiology and Cardiac Imaging and importantly, to legitimize the SHD imager as the secondprocedure operator, equally dedicated to exceptional patient care. 646