Is It Time for an ‘Interventional Heart Failure’ Subspecialty?

The emerging subspecialty of interventional heart failure could help fill the gap in trained physicians available to treat an increasingly complex group of patients, experts argue in a new consensus document. However, integrating training paradigms from two traditionally separate pathways—interventional cardiology and advanced heart failure and transplant cardiology (AHFTC)—will pose challenges, they say.

The US heart failure community has been sounding the alarm for several years that unfilled training positions in AHFTC will adversely affect this growing patient population. Proposals such as training internists in HF care have gained traction, while others have noted that interventional cardiologists have experience relevant to HF patient and research needs.

In the new paper, published online last week in JSCAI, Richard Cheng, MD (University of California, San Francisco), and colleagues outline the core tenets of interventional heart failure and how a dual training protocol might attract more physicians.

“The field has been around for some time, but it’s really picking up steam because of all these devices, innovations, and growth in the heart failure space,” said Cheng, who has trained in heart failure, interventional cardiology, and structural interventions. The notion of interventional heart failure goes back at least 20 years, he told TCTMD, noting that it began with electrophysiologists using device-based interventions like pacemakers to treat patients with heart failure.

With an “explosion” in heart failure technology, including mechanical circulatory support devices, hitting the market over the past 6 years, “that puts a renewed focus on what interventional heart failure is and why this is needed in the future,” Cheng said.

Co-author Marat Fudim, MD (Duke University Medical Center, Durham, NC), who served on a panel last week in the opening session of THT 2025 where this paper was discussed, told TCTMD that an increasingly important question is: “How do we reinvigorate interest in the space of heart failure?”

Fudim said he is a “big advocate [of] specifically making the space more attractive,” especially since the AHFTC career pathway has long been associated with less pay, limited jobs, and a low volume of procedures.

As a heart failure fellow 5 years ago, Fudim inquired about also training in interventional cardiology so that he could better provide a continuum of care to his patients but was discouraged from that career pathway by mentors due to lack of precedent as well as concerns over job availability. He ended up spending extra time in the cath lab to learn interventional skills and now calls himself the “the Energizer bunny for this field.”

“We have [seen] the best talent in cardiology, which is already very talented people, leave for procedural fields because they don’t want to be just ‘pill pushers,’” Fudim said. Changing the perception of what it means to be a heart failure doctor—potentially by attracting proceduralists by creating an official interventional heart failure training pathway—is likely to not only increase job satisfaction for these physicians but also allow for better patient care, he added.

Pragmatic Integration

In the consensus paper, Cheng, Fudim, and colleagues explore what a career in interventional heart failure could look like and review several pathways in which a physician might train. Right now, fellows could complete a 3-year general cardiology fellowship, followed, in no particular order, by 1 year of interventional training, 1 year of advanced heart failure and transplant, and potentially also 1 year of structural heart interventions.

“The field of interventional heart failure has been misunderstood as one of ‘jack of all trades’ but actually represents the trend of increasing specialization for careers within cardiology due to the increasing complexity of therapeutic options within CVD,” the authors write.

They recommend integration of the two fields into a dual training pathway but recognize the potential issues with bringing that to fruition, including ensuring clinical competency with limited time.

Cheng acknowledged the challenge that heterogeneity in this field can bring. “We try our best to define the phenotypes that are working right now in the United States and Europe of folks that are practicing both [interventional cardiology and heart failure],” he said. “The next big hurdle is to . . . continue to recognize the need” for people to train specifically in heart failure, whether through a dedicated fellowship or potentially ad hoc. 

“We need to integrate interventional heart failure into existing training pathways to start and to be very pragmatic about that,” Cheng continued, specifying that this could even mean incorporating more interventional heart failure training into general cardiology fellowship. Additionally, it would take foresight on the part of programs to look for candidates who would commit to 2 years even though it might mean going through two match processes.

For now, Fudim said the plan is not to overhaul the academic process for people interested in interventional heart failure, but rather to “show students that there are pathways and mentors that have done it successfully, [and] we can slowly build this wave of a new generation of docs that cross those two specialties.”

Next, Cheng hopes to see a set of training competencies published for the field of interventional heart failure to further promote careers in this area. From there, he said, “I’d like to see in the future [that] programs that offer interventional cardiology training and heart failure training can integrate the interventional heart failure curriculum into their existing pathways.”