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 6.2.2.11.4. Acquisition of Competence and Training Models Once these prerequisites have been met, the acquisition of competence for an operator to become independent in this intervention should follow a structured, consistent model. Training should involve practical activities that include simulation of cases of transseptal puncture and implantation of LAA occluder prostheses, with manipulation of the material utilized during the procedure. During the first effective implants, the operator should be assisted by a medical instructor (proctor) with proven experience in the intervention. The duration of the learning curve for LAAO varies significantly, in accordance with the operator’s degree of familiarity with congenital and/or structural heart disease procedures and the frequency with which the procedure is performed. There is no consensus in the literature with respect to the minimum number of cases required in order to complete this learning curve; 39,40 nevertheless, within the Brazilian context, considering the complexity of the intervention, the practical experience of the authors of these guidelines has made it possible to estimate that a beginner operator reaches the level of proficiency and safety necessary for LAAO once he or she has performed approximately ten cases. Although all of the prostheses available in the Brazilian market follow different requirements and implantation techniques, there is a “group effect” in learning the general technique, which allows for partial sharing of the learning curves between prosteses. 39,41 6.2.2.12. Transcatheter Aortic Valve Replacement AoS currently shows a growing prevalence due to increased life expectancy and consequent population aging. Currently, the most common cause of AoS is aortic calcification, which mainly affects elderly patients, being observed at a prevalence of 4.6% in individuals over 75 years old. 42-44 TAVR has become an option for surgical valve replacement in select cases following careful assessment of life expectancy, degree of frailty, and aortic valve anatomy. 43,45-52 Interventional cardiologists who perform this procedure should have extensive knowledge of the results, limitations, and complications of medical therapy, aortic valve replacement, stimulation with a pacemaker, and TAVR itself. 45-52 It is recommended that TAVR involve a multidisciplinary program that includes the contributions of a clinical cardiologist, an echocardiographist, a radiologist, and a cardiac surgeon. The following are, furthermore, recommended for the operator in accordance with the joint resolution established between the SBHCI and the Brazilian Society of Cardiovascular Surgery (Sociedade Brasileira de Cirurgia Cardiovascular – SBCCV) in January 2017: • A certificate in the area of hemodynamics and interventional cardiology. • Participation in theoretical didactic sessions, with a minimum course load of 24 hours, in courses administrated or recognized by the SBHCI and the SBCCV. • Participation in training sessions with simulators, with a minimum course load of 2 hours. • Participation, as an observer, in at least two TAVR procedures in training centers accredited by Brazilian medical societies or care centers that regularly contribute to the Brazilian Registry of Transcatheter Aortic Valve Bioprosthesis Implantation, as certified by the coordinator of the Center. • Participation in discussions of clinical cases related to TAVR procedures, with a minimum course load of four hours, in training centers accredited by the medical societies, as certified by the coordinator of the Center. • In transfemoral procedures, perform a minimum of five procedures over the past two years, as a first operator, under the supervision of a qualified specialist (proctor). • Proficiency and autonomy attested by a supervisor specialist accredited by the SBCCV and the SBHCI (at the supervisor’s discretion, training may be extended to a higher number of supervised cases). • Contribution to the Brazilian Registry of Catheter Valve Therapy during at least the first 25 procedures, performed without supervision. Candidates for TAVR Qualification Certificates must submit the proof of training documents to the Certification Committee of the SBHCI and the SBCCV, in order to verify that they have met the previously described requirements. Candidates who undergo training in TAVR abroad may be certified, provided that they have met the requirements established here and that they present documentation which proves that they have completed training, with the signature of the technical manager of the institution. 6.2.2.12.1. Basic Knowledge • Natural history and etiology of aortic valve stenosis. • Hemodynamics of left ventricular outlet obstructions. • Interpretation and familiarity with different imaging exams: TTE, TEE, CT, MR, and angiography. • Knowledge of current guidelines for aortic valve stenosis. • Therapeutic options. • Indications for intervention. 6.2.2.12.2. Interventional Cardiologists’ Abilities • Hemodynamic interpretation of pressure curves. • Choice of vascular access. • Introducers, wires, and catheters utilized. • Angiographic projections for performing the procedure. • Pre-procedure assessment of CT and other exams for procedure planning. • Right ventricular pacemaker during intervention (rapid pacing). • Crossing of the aortic valve orifice with diverse guidewires for positioning inside the left ventricle. • Performance of balloon aortic valvuloplasty. • Recognition and rapid management of complications (vascular complications, coronary occlusion, stroke, cardiac tamponade, hemodynamic collapse, iatrogenic IVC, cardiac perforations, arrhythmias/atrioventricular blocks, etc.). • Immediate and long-term post-procedural care. 153