Core Competencies Defined for Echo, Cardiac CT in Structural Interventions

With the growing volume of structural heart interventions, two cardiac-imaging teams have published core competency papers regarding the use of echocardiography and cardiac CT as well as the necessary training in these tools.

This is not the first time structural heart imagers have called for greater consistency and increased visibility as a subspecialty. Many newer procedures like TAVR and, more recently, mitral and tricuspid interventions cannot be completed without a competent cardiac imager, yet institutions generally don’t recognize these physicians’ contributions through traditional reimbursement models.

Both papers were written at the request of the editor of JACC: Cardiovascular Imaging, Y. Chandrashekhar, MD (University of Minnesota, Minneapolis), and published in the journal yesterday.

Jonathon Leipsic, MD (St Paul’s Hospital, Vancouver, Canada), the lead author of the core competency paper on cardiac CT, told TCTMD that he fielded some hesitation from experts about the timing of a paper like this given the maturity of the field. “My feeling was that we have to start somewhere,” he said. “Obviously they're not to be binding and they're not to drive reimbursement, but it does give some benchmarks for new sites as they integrate CT perhaps or they start doing TAVR. . . . Until now, it's really been left entirely up to sites. There's been zero definition of quantity measures that may be required to be somewhat competent in this.”

In agreement, Rebecca Hahn, MD (NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY), the lead author of the echocardiography paper, told TCTMD that the multidisciplinary nature of cardiac imaging has led it to be “not really yet recognized as a subspecialty, even though those of us that are doing it clearly have additional skills.” Hahn stressed that these papers are not guidelines or society-endorsed consensus documents, but rather each represent “a consensus of experts who are all involved . . . in imaging for these procedures.”

Training protocols have been poorly defined both for those interested in performing the interventions and those wishing to image them, she continued. “To start the conversation, we wanted to have a specific document that brought up some of the issues and perhaps emphasized some of the differences that makes this a new subspecialty.”

Acknowledgment and Communication

Recognition is the first step to the success of structural heart imaging, Hahn said. “If we were to accomplish at least the goal of individuals, certainly, but [also] institutions and then societies, recognizing that the imaging for structural heart disease interventions is a new subspecialty requiring special skills, that in and of itself would be a major step forward,” she said. “Then we can start the conversation about requirements and actual formal training and supporting the individuals not only for training purposes but also for the work that they do during the procedures.”

In terms of reimbursement, Hahn said many imagers have had to “jerry-rig” various methods of making their salaries because most institutions won’t enable them to be easily reimbursed for their day-to-day activities. “That's not appropriate at this point given the importance of the imager within these interventions,” she said. “Many of the interventions cannot even happen without the imager, and so for them to struggle to make their salary I think is not reasonable, and [that’s] where we fall apart a little bit in getting administrative and institutional support.”

At her institution, the cath lab employs the cardiac echocardiographers who work on structural heart procedures on a salary basis. Another solution is for the interventionalists to share RVUs with imagers on imaging-intense cases, Hahn said.

As for training, Leipsic said he’s seen the full gamut of various curricula. His institution trains several fellows in both coronary and structural CT. “I don't know whether a year for CT is realistic for structural alone, but I think as coronary CT grows, it becomes more and more realistic for more sites to offer dedicated training,” he said, adding that some institutions might start offering 2-year combined structural CT and echocardiography programs as well.

“What we would like to avoid is just having an untrained imager going into these procedures [as] outcomes will be determined in part by the experience of both the interventionalist and the imager,” Hahn said. “The interventionalists are still having trouble themselves determining what their minimum requirements should be. So that's a moving target as well. And so ours will also be a moving target, but it will be in parallel with those requirements of the interventionalist.”

It ultimately comes down to good communication and teamwork, skills that need to be drummed into imaging trainees as well, according to Hahn. “What we've all learned is that the imagers on the heart team play such an important role in not only device development and procedural success but in all aspects of patient care in this really complex field,” she said. “The team needs to be built with mutual respect and really open lines of communication, something . . . that imagers really aren't all that used to. They're not used to having to communicate in that way on an equal footing with an equal voice in a procedure as the interventionalist. And yet, you have to in order for these procedures to be technically successful.”

“I always tell my trainees: you can be the best at interpreting a TAVR CT, but if you're not at the multidisciplinary rounds for the heart team discussion—if not for all of them, at least at the majority—you're not really part of the team and you're not adding value,” Leipsic said. “You really need to understand the subtleties of device selection and treatment planning, so that's something that we really try to highlight. Whether you're a radiologist or a cardiologist, whatever your training, you can't just be trained in the methodology of interpreting the CT. You really need to understand the nuances of treatment decision making and to be part of the heart team.”

Looking forward, both Hahn and Leipsic said they would like to see more formalized, society-endorsed consensus documents for echocardiography and CT in structural heart interventions, respectively. “Most of these recommendations are going to be opinion-based,” Leipsic noted. “They're not obviously supported by randomized trials or even any evidence—it's just a gestalt based on expert people as far as how much training one needs to be competent in this space.”