ABC | Volume 114, Nº1, January 2019

Statement Position Statement of the Brazilian Cardiology Society and the Brazilian Society of Hemodynamics and Interventional Cardiology on Training Centers and Professional Certification in Hemodynamics and Interventional Cardiology – 2020 Arq Bras Cardiol. 2020; 114(1):137-193 6.1.2.5.2. Interventional Cardiologists’ Abilities • Knowledge and proper handling of sheaths, guidewires, and catheters utilized. • Choice of vascular access. • Hemodynamic and angiographic assessment of surgical conduits and tunnels. • Knowledge and appropriate choice of different balloons, stents, and covered stents available for this procedure and their techniques. • Recognition and treatment of acute complications. • Medium and long-term care and orientations for the patient. 6.2. Structural Heart Diseases Structural heart diseases encompasses congenital and acquired conditions that involve major cardiovascular structures, excluding coronary atherosclerotic and peripheral vascular diseases. Formal training in structural and congenital heart diseases in adults takes place during the specialization phase, even in developed countries. 8 With the advent of percutaneous interventions for the treatment of structural defects and valve diseases, such as TAVR, TPVI, and TMVR, as well as the expansion of occlusion procedures with intra- and extracardiac shunts, among others, it is clear that there is a need to create basic requirements for training interventional cardiologists who are interested in performing these procedures. As the complexity of the conditions increases, the level of training goes from a “basic” stage to more “advanced” levels. Training for occlusion of atrial septal defects requires less advanced abilities and tools than those that are required for mitral paravalvular leak closure, for instance. Training in formation centers should seek to hierarchize this process. In the same manner, for interventional cardiologists who are already acting in the field, the tutorial process, with the figure of an instructor or proctor, is fundamental to determining which steps to go through, from less complex to more complex scenarios. 6.2.1. Basic Interventions in Structural Cardiovascular Diseases 6.2.1.1. Catheterization of Left Chambers following Transseptal Puncture 6.2.1.1.1. Basic Knowledge • Normal anatomy and morphospatial variations resulting from diverse conditions (right and/or left atrial dilatation, ascending aortic dilatation, dextrocardia, heterotaxy, etc.). • Hemodynamic interpretation of pressure curves. • Appropriate assessment and recognition of atrial septal structures by means of diverse imaging methods: TTE, TEE, intracardiac echocardiography, and fluoroscopic markers. • Indications for intervention. 6.2.1.1.2. Interventional Cardiologists’ Abilities • Percutaneous access for transseptal puncture. • Transseptal introducers, wires, needles, and other devices, such as radiofrequency. • Selective puncture guided by TEE. 6.2.1.2. Aortic Valvuloplasty in Adults 6.2.1.2.1. Basic Knowledge • Natural history and etiology of AoS. • Hemodynamics of severe AoS with high and low gradients. • Interpretation and familiarity with different imaging exams of the aortic valve: TTE, TEE, CT, MR, angiography. • Knowledge of current guidelines for treatment of AoS. • Therapeutic options and outcomes. • Indications for intervention. 6.2.1.2.2. Interventional Cardiologists’ Abilities • Hemodynamic interpretation of AoS. • Access choice. • Techniques for crossing the stenotic aortic valve. • Sheaths, wires, and catheters utilized. • Balloon catheters for valvuloplasty. • Stimulation of very high frequencies by means of a pacemaker (rapid pacing). • Familiarity in managing devices for vascular suture. • Recognition and rapid management of complications (vascular occlusions, dissections, thromboembolism, hemodynamic collapse, retroperitoneal bleeding, cardiac perforations, arrhythmias/atrioventricular blocks, coronary occlusion, etc). • Immediate and long-term post-procedural care. 6.2.1.3. Patent Foramen Ovale Occlusion PFO is observed in approximately 25% of the general population, and it may thus coexist, by chance, in patients with strokes or thromboembolic phenomena that are undefined in nature. 9 Epidemiological data, however, have established a clear relation between PFO and stroke of undetermined origin. 10-14 Additionally, studies have documented higher rates of systemic embolization among patients who have venous thrombosis or debris and concomitant PFO. 15-18 Many reports have also demonstrated direct evidence of thrombi adherent to the PFO. 19,20 Finally, and most importantly, randomized studies have demonstrated that PFO occlusion significantly reduces stroke recurrence in comparison with isolated medical therapy. 21-24 Based on a document signed by several European scientific societies, PFO occlusion or closure in the scenario of stroke or paradoxical systemic embolic events of undefined causes (related to PFO) should be performed in select patients, between the ages of 18 and 65, as a form of secondary 148